ES3000080T3 - Acromion fracture repair system - Google Patents

Abstract

A kit including (1) a plate configured to be secured to a scapular spine with a first end of the plate proximate a trigone and a second end of the plate proximate an acromion; (2) a first hook including a backing, a first hook portion extending from the backing in a first direction, a spacer extending from the first hook portion in a transverse direction, and a second hook portion extending from an opposite end of the spacer in the first direction, the first hook adapted to extend around a lateral end of the acromion when secured to the second end of the plate; and (3) a second hook including a backing, a curved portion curving away from the backing, and a hook portion at an opposite end of the curved portion, the second hook adapted to extend around the trigone when secured to the first end of the plate. (Automatic translation with Google Translate, no legal value)

Description

DESCRIPTION

Acromion Fracture Repair System

This application is a related international patent application (PCT) related to and claiming the benefit of co-pending U.S. provisional patent application No. 62/883,414, filed August 6, 2019, entitled "ACROMION FRACTURE REPAIR SYSTEM."

Field of Invention

The field of the invention relates to devices for orthopedic use. More particularly, the field of the invention relates to devices for use in the reconstruction of fatigue/insufficiency of the acromion and scapula that may occur after reverse total shoulder arthroplasty.

Background of the invention

EP 3135234 A1 relates to a three-dimensional fracture fixation device for treating clavicle fracture with the intention of protecting the supraclavicular nerve from subsequent iatrogenic transectional injury that may occur when the fixation bone plate is removed. The components of the three-dimensional fracture fixation device include at least a fixation locking plate, a nerve protection scutum (shield), connecting hooks connecting the fixation locking plate and supporting the nerve protection scutum (shield), and bone screws, which are assembled to form a defined space to accommodate the supraclavicular nerve during open reduction and internal fixation.

EP 1 743 586 A1 relates to a bone plate for use in fitting a clavicle, comprising an elongated portion and an arch portion, the elongated portion having a curve approximately in the shape of the anterior surface of the clavicle, the arch portion being adapted to fit over a clavicle in the region of the acromial end thereof.

Reverse total shoulder arthroplasty (rTSA) is a surgical technique in which the natural ball-and-socket joint of the shoulder, which has a rounded humeral head (i.e., ball) that interfaces with the glenoid cavity (i.e., socket) of the scapula, is replaced with a reverse ball-and-socket joint, which has a glenosphere (i.e., ball) implanted in the shoulder and mates with a cup (i.e., socket) implanted in the humerus. Occasionally, fatigue/insufficiency fractures occur in the acromion and scapula after rTSA. Reconstruction of acromial and scapular fatigue/insufficiency fractures after rTSA is a challenging and unsolved problem. These types of fractures cannot always be repaired; and healing after repair is not always reproducible even for the best shoulder specialists and trauma surgeons due to the highly variable anatomy, which often consists of relatively thin bone with low vascularity. There is no ideal method for repairing acromial and scapular fatigue fractures, and only a few solutions are currently available for open reduction and internal fixation (ORIF) surgery. When using ORIF, shoulder specialists and trauma surgeons primarily use one or more straight/noncontoured plates with locking screws, compression screws, and/or a combination of each. Due to the highly variable scapular anatomy in terms of size and shape/contour, few anatomically contoured plates are available, and surgeons are often required to bend straight plates to obtain a better fit. Due to repair and healing concerns, the most common treatment method is immobilization of the patient's arm in a sling until the fracture heals. For both ORIF and immobilization, the healing rate is unpredictable. Figure 1A shows a representative radiographic representation of a shoulder joint after rTSA and before scapular fracture, while Figure 1B shows a representative radiographic representation of the shoulder joint after scapular fracture following rTSA.

Recently, rTSA outcome studies have shown that even if a fatigue/insufficiency fracture heals, the patient will not achieve the level of outcome and function experienced before the fracture. If the fracture does not heal, outcomes are poor because the origin of the medial deltoid is on the acromion and the origin of the posterior deltoid is on the lateral acromion and scapular spine. Without adequate deltoid function, the reverse shoulder prosthesis cannot generate the torque necessary for activities of daily living, and joint stability is compromised.

Acromial and scapular fatigue/insufficiency fractures can occur at any time after the initial rTSA procedure, from the first day of surgery up to more than 10 years after the surgical procedure. Acromial and scapular fatigue/insufficiency fractures after rTSA can occur at various locations in the acromion and scapular spine. These fracture types have been classified as type 1 (lateral acromion fracture with a deltoid avulsion), type 2 (midscapular spine fracture at or around the scapular notch), and type 3 (fracture at the base of the scapular spine). Figures 2A, 2B, and 2C show the superior, posterior, and superior-obligate views, respectively, of the portions of the acromion that fracture as a result of these different types of fractures. Figures 3A and 3B show a superior view and a posterior view, respectively, of a healthy scapula. Figures 3C and 3D show a superior view and a posterior view, respectively, of a scapula that has experienced a type 1 fracture. Figures 3E and 3F show a superior view and a posterior view, respectively, of a scapula that has experienced a type 2 fracture. Figures 3G and 3H show a superior view and a posterior view, respectively, of a scapula that has experienced a type 3 fracture. The rate of acromial and scapular fatigue/insufficiency fractures after rTSA is relatively low but is generally reported to be between 1 and 10%. Type 2 fractures appear to be the most common type of scapular insufficiency fracture after rTSA.

There are numerous potential causes of these acromial and scapular insufficiency/fatigue fractures. Some believe the fracture propagates from the tip of the glenoid plate screw into the scapular spine, while others postulate that the fractures occur due to overactivity or episodes of strenuous activity and/or trauma, and still others believe the fracture is caused by over-tensioning of the deltoid and/or lengthening of the arm based on overfilling the joint with an implant that is too thick or too distal of an implant configuration for a given patient's anatomy. Still other considerations include the use of biomechanically inefficient implants that have too small a deltoid moment arm (resulting in too great a deltoid force for arm elevation for a particular patient). There are also likely patient-specific anatomic/morphologic factors that predispose the patient to these types of insufficiency fractures, such as a thin scapula/acromion, osteoporotic or osteopenic bone, the presence of an acromiale or lesion associated with CTA pathology, or perhaps a unique biomechanically detrimental anatomy such that there is insufficient acromial protrusion or muscle mass, requiring the patient to produce abnormal physiologic loading during daily weight-bearing activities. Patients with rTSA are associated with more scapular motion relative to patients without rTSA, and it may be that the amount of scapular rotation influences this complication. The timing and level of rigor of the rehabilitation program may also play a role in the rate and severity of acromial or scapular fatigue/insufficiency fracture. These fractures could also be caused during surgery by traction with a retractor when attempting to gain exposure to the glenoid. Whatever the specific cause (or combination of causes), the patient population is predominantly female, osteoporotic, and older. As a result, the fracture is at a disadvantage for healing; the patient's health status and comorbidities also influence the quality of fracture reconstruction and the rate and likelihood of fracture healing over time.

The widespread and global use of rTSA since its elimination in the US in 2003 and the lack of a consensus solution for this type of complication highlights the need for a better solution for acromial/scapular insufficiency fractures after rTSA, but also highlights the need for a solution if fracture reconstruction fails, which has been reported at a relatively high rate due to patient and anatomic factors. For all these reasons, there is a need for a more effective solution to restore patient function and stability with rTSA after an acromial/scapular insufficiency fatigue fracture.

Brief description of the figures

Some embodiments of the invention are described herein, by way of example only, with reference to the accompanying drawings. With specific reference now to the detailed drawings, it is emphasized that the details shown are exemplary and for the purpose of illustrative discussion of embodiments of the invention. In this regard, the description taken with the drawings makes it evident to those skilled in the art how embodiments of the invention can be put into practice.

Figure 1A shows an anterior-posterior radiographic view of a shoulder joint after rTSA and before scapular fracture;

Figure 1B shows the rTSA shoulder joint from Figure 1A after scapular fracture;

Figure 2A shows a top view of the locations of different scapular fractures;

Figure 2B shows a posterior view of the scapular fractures shown in Figure 2A;

Figure 2C shows a superior oblique view of the scapular fractures shown in Figure 2A;

Figure 3A shows a superior view of a healthy scapula;

Figure 3B shows a posterior view of the healthy scapula shown in Figure 3A;

Figure 3C shows a superior view of a scapula after a Type 1 fracture; Figure 3D shows a posterior view of the fractured scapula shown in Figure 3C; Figure 3E shows a superior view of a scapula after a Type 2 fracture;

Figure 3F shows a posterior view of the fractured scapula shown in Figure 3E; Figure 3G shows a superior view of a scapula after a Type 3 fracture;

Figure 3H shows a posterior view of the fractured scapula shown in Figure 3G; Figure 4A shows a first modular hook;

Figure 4B shows a second modular hook;

Figure 4C shows a third modular hook;

Figure 4D shows two of the third modular hook of Figure 4C attached to a base;

Figure 5A shows a first plate;

Figure 5B shows a reverse view of the first plate of Figure 5A;

Figure 5C shows the first plate of Figure 5A configured with hooks;

Figure 5D shows a reverse view of the plate and hooks of Figure 5C;

Figure 5E shows the first plate and hooks from Figure 5C secured to a representative scapula;

Figure 6A shows a perspective view of a second plate;

Figure 6B shows a reverse perspective view of the second plate of Figure 6A;

Figure 6C shows the second plate of Figure 6A configured with a hook;

Figure 6D shows an alternate view of the second plate and hook of Figure 6C;

Figure 6E shows the second plate and hook of Figures 6C and 6D secured to a representative scapula;

Figure 6F shows an alternate view of the second plate and the representative hook and scapula of Figure 6E;

Figure 7 A shows a third plate;

Figure 7B shows a reverse view of the third plate of Figure 7A;

Figure 7C shows the third plate of Figure 7A configured with hooks;

Figure 7D shows an alternate view of the third plate and hooks of Figure 7C;

Figure 7E shows the third plate and hooks from Figures 7C and 7D secured to a representative scapula;

Figure 7F shows an alternate view of the third plate and hooks and representative scapula of Figure 7E;

Figure 8A shows a fourth plate which is an adjustable plate;

Figure 8B shows an alternative configuration of the fourth plate of Figure 8B;

Figure 8C shows the fourth plate of Figure 8A with an acromial plate from it placed in two alternative positions;

Figure 8D shows the fourth plate of Figures 8A and 8B positioned with reference to a representative scapula; and

Figure 8E shows an alternate view of the fourth plate and the representative scapula of Figure 8D.

Brief description of the invention

The present invention relates to a kit as defined in independent claim 1, while preferred embodiments are set forth in the dependent claims. Associated methods are also described herein to aid in understanding the invention. These methods do not form part of the claimed invention.

The invention relates to devices for repairing acromial/scapular fractures. In some embodiments, the devices described herein are suitable for use in reconstructing the acromion and scapula of patients with rTSA who have insufficiency fractures of the acromion or scapula.

In one embodiment, a scapula repair device includes a fracture fixation bone plate (referred to herein as a "plate" for brevity) having a first end, a second end opposite the first end, and at least one fixation point positioned along the plate between the first end and the second end; at least one hook, each of the at least one hook being mounted to a corresponding one of the at least one fixation points of the plate; and at least one fixation element, each of the at least one fixation element is positioned to secure a corresponding one of the at least one hook to a corresponding one of the at least one fixation point and to secure the plate to a scapula of a patient, wherein the plate is configured such that, when the plate is secured to the scapula of the patient, the plate extends along at least a portion of a scapular spine of the scapula and at least a portion of an acromion of the scapula, and wherein the plate and the at least one hook are configured such that, when the plate is secured to the scapula of the patient, the plate and the at least one hook cooperate to retain the acromion and/or the scapula in a desired position. In some embodiments, such retention of the acromion and/or scapula is suitable for facilitating healing of a fracture, such as a fracture of one of the three different fracture types that occur after rTSA (e.g., as described above with reference to Figures 3A-3H).

In one embodiment, a kit includes at least one plate having a first end, a second end opposite the first end, and at least one attachment point positioned along the plate between the first end and the second end, wherein each at least one plate is configured such that, when the at least one plate is secured to a scapula of a patient, at least one of the plates extends along at least a portion of a scapular spine of the scapula and at least a portion of an acromion of the spine; a plurality of hooks, each of the plurality of hooks configured to attach to a selected point of the at least one attachment point of a plate selected from the at least one plate; a plurality of fixation elements, each of the fixation elements configured to fix a selected one of the plurality of hooks to the selected one of the at least one fixation point of the selected one of the at least one plate and to secure the selected one of the at least one plate to the scapula of the patient, wherein each of the at least one plate and each of the at least one hook are configured such that, when a selected one of the at least one hook is secured to the selected one of the at least one plate and the selected one of the at least one plate is secured to the scapula of the patient, the selected one of the at least one plate and the selected one of the at least one hook cooperate to retain the acromion in a desired position.

In some embodiments, a kit includes at least one plate and a plurality of hooks, wherein each of the at least one plate includes a plurality of attachment points that are spaced apart along each of the at least one plate, wherein the at least one plate includes at least a first plate that is an elongated plate having a first end and a second end opposite the first end, wherein the first plate is sized and shaped to be configured to be positioned and extend along a scapular spine of a scapula of a patient such that the first end is proximate a trigone of the scapula and the second end is proximate an acromion of the scapula and configured to attach to the scapular spine, wherein each of the hooks is configured to attach to a selected one of the attachment points of a selected one of the at least one plate, wherein the plurality of hooks includes at least a first hook that includes (1) a mount that is configured to attach to a selected one of the attachment points. fixation of a selected one of the at least one plate, (2) a first hook portion positioned proximate the mount and extending away from the mount in a first direction, (3) a spacer portion extending away from the first hook portion in a transverse direction that is perpendicular to the first direction, and (4) a second hook portion extending from an end of the spacer portion that is opposite the first hook portion and extending in the first direction, wherein the first hook is sized and shaped to be configured so that the first and second hook portions extend around a lateral end of the acromion when the first hook is fixed to a first one of the fixation points of the first plate that is proximate the second end of the plate, and a second hook including (1) a mount that is configured to fix to a selected one of the fixation points of a selected one of the at least one plate, (2) a curved portion that extends away from and curves back toward the mount, and (3) a hook portion at one end of the curved portion that is opposite the mount of the second hook, wherein the second hook is sized and shaped to be configured so that the hook portion of the second hook extends around the trigone of the scapula when the second hook is fixed to a second of the fixation points of the first plate that is proximate the first end of the first plate.

In some embodiments, the first plate is contoured to fit the scapular spine.

In some embodiments, at least one of the at least one plate is adaptable to allow a user to adapt the plate to a portion of the scapula.

In some embodiments, the hook portion of the second hook is Y-shaped.

In some embodiments, the first plate, the first hook, and the second hook are configured to cooperate to apply a compressive force to a fracture along the scapular spine when (a) the first plate is secured to the scapular spine, (b) the first hook is attached to the first of the attachment points of the first plate and positioned such that the first and second hook portions of the first hook extend around the lateral end of the acromion, and (c) the second hook is attached to the second of the attachment points of the first plate and positioned such that the hook portion of the second hook extends around the trigone of the scapula.

In some embodiments, a kit also includes at least one fastener configured to attach to one of the attachment points of one of the at least one plate, the plate, and the scapula to attach the one of the at least one plate to the scapula.

In some embodiments, a kit also includes at least one fastener configured to be secured to one of the attachment points of one of the at least one plate and to a selected one of the plurality of hooks for securing the selected one of the plurality of hooks to the one of the at least one plate.

In some embodiments, the at least one plate also includes a second plate, wherein the second plate has a first end and a second end opposite the first end of the second plate, wherein the second plate is a curved plate that is sized and shaped to be configured to be positioned adjacent to the patient's scapular spine and the patient's acromion such that the first end of the second plate is positioned proximate the patient's trigone and the plate extends along the patient's scapular spine and the patient's acromion to the second end which is positioned proximate a superior portion of the patient's acromion.

In some embodiments, the second hook is sized and shaped to be configured such that the hook portion of the second hook extends around the top of the patient's acromion when the second hook is attached to one of the attachment points of the second plate that is located near the second end of the second plate.

In some embodiments, the at least one plate includes a second plate which is an elongated plate having a first end and a second end opposite the first end of the second plate, wherein the second plate is sized and shaped to be configured to be positioned along the scapular spine and extend along the scapular spine from the first end which is positioned along an inferior surface of the scapular spine to the second end which is positioned on a posterior surface of the acromion. In some embodiments, the plurality of hooks includes a third hook including (1) a mount that is configured to attach to a selected one of the attachment points of a selected one of the at least one plate, (2) a curved portion extending away from and curving back toward the mount, and (3) a hook portion at an end of the curved portion that is opposite the mount from the second hook, and (4) an attachment hole extending through the hook portion, wherein the attachment hole is configured to receive a fastener for attaching the hook portion to the scapula. In some embodiments, the third hook is sized and shaped to be configured such that the hook portion extends over an upper surface of the scapular spine when the second plate is positioned along the scapular spine and the second hook is attached to one of the attachment points of the second plate that is positioned along a lower surface of the scapular spine. In some embodiments, the kit also includes a fastener that is configured to attach to both the mount and the third hook attachment hole. In some embodiments, the fastener is configured to extend across the mount, the scapular spine, and the third hook attachment hole when (a) the second plate is positioned along the scapular spine and (b) the third hook is attached to one of the attachment points of the second plate that is positioned along the lower surface of the scapular spine such that the hook portion of the third hook extends over the upper surface of the scapular spine.

In some embodiments (not forming part of the claimed invention), a method includes (1) providing a kit that includes at least one plate, a plurality of hooks, and a plurality of fasteners; wherein each of the at least one plate includes a plurality of attachment points that are spaced apart along each of the at least one plate, wherein the at least one plate includes at least a first plate that is an elongated plate having a first end and a second end opposite the first end, wherein the first plate is sized and shaped to be configured to be positioned and extend along a scapular spine of a scapula of a patient such that the first end is proximate a trigone of the scapula and the second end is proximate an acromion of the scapula and configured to attach to the scapular spine, and wherein each of the hooks is configured to attach to a selected one of the attachment points of a selected one of the at least one plate, wherein a first hook of the plurality of hooks includes (a) a mount that is configured to attach to a selected one of the attachment points of a selected one of the at least one plate, (b) a first hook portion positioned (c) a spacer portion extending away from the first hook portion in a transverse direction that is perpendicular to the first direction, and (d) a second hook portion extending from an end of the spacer portion that is opposite the first hook portion and extending in the first direction, wherein the first hook is sized and shaped to be configured so that the first and second hook portions extend around a lateral end of the acromion when the first hook is attached to a first one of the attachment points of the first plate that is proximate the second end of the plate, and wherein a second hook of the plurality of hooks includes (a) a mount that is configured to attach to a selected one of the attachment points of a selected one of the at least one plate, (b) a curved portion extending away from and curving rearwardly toward the mount, and (c) a hook portion at an end of the curved portion that is opposite the mount of the second hook, wherein the second hook is sized and shaped to be configured such that the hook portion of the second hook extends around the trigone of the scapula when the second hook is attached to a second one of the attachment points of the first plate that is proximate the first end of the first plate; (2) attaching the first hook to the first one of the attachment points of the first plate with a first one of the plurality of fasteners; (3) attaching the second hook to the second one of the attachment points of the first plate with a second one of the plurality of fasteners; (4) positioning the first plate along a scapular spine of a scapula of a patient such that the first end is proximate a trigone of the scapula and the second end is proximate an acromion of the scapula; and (5) fastening the first plate, the first hook, and the second hook to the scapular spine with at least a third of the plurality of fasteners such that the first hook extends around a lateral end of the acromion, such that the second hook extends around the trigone, and such that the first plate, the first hook, and the second hook cooperate to apply a compressive force along the scapular spine.

Detailed description of the invention

Embodiments relate to a fracture fixation system for patients with acromial and scapular fractures following rTSA. In some embodiments, an exemplary fracture fixation system restores stability to the shoulder with a fractured acromion and/or scapula by using a scapular plating system that includes at least one modular hook that secures around at least one corresponding anatomical scapular feature (e.g., the acromion, scapular spine, or scapular trigone). In some embodiments, the at least one hook is monolithic with a plate (e.g., integrally formed from a single piece of plate material). In some embodiments, the at least one hook is modularly secured to a plate with a mechanical locking mechanism. In some embodiments, the plate construct (e.g., a plate including at least one integrally formed hook, a plate including at least one modularly attached hook, etc.) may be secured to the scapula with the aid of screws, sutures, wire, and/or pins.

In some embodiments, a plate used in connection with at least one modular hook facilitates a simpler surgical technique through a smaller incision, while improving availability to account for multiple diverse anatomical size ranges (e.g., by providing modular hooks of various shapes and sizes) to account for variable scapular anatomy/morphology, thereby reducing the overall scope and cost of the kit required to account for the anatomical variability required for the global market. In some embodiments, a plate used in connection with at least one modular hook simplifies the manufacturing process and requires a lower cost for all implants in the kit (e.g., by allowing mixing and matching of different configurations).

In some embodiments, a plate used in connection with at least one modular hook may be placed at morphologically/anatomically strategic locations on a bone, tailored to each patient's individual fracture type (e.g., Type 1, 2, or 3). For example, such modular hooks may be placed at the lateral acromion (see, e.g., Figures 5E and 5F) or directed toward the medial portion of the acromion. Figures 5E and 5F also show such holes secured along the medial scapular border, at or around the scapular trigone. Similarly, the modular hooks may be placed along the anterior portion of the acromion (see, e.g., Figures 6E and 6F) or instead directed toward the posterior portion of the acromion if the orthopedic/trauma surgeon deems that location facilitates the best reconstruction. Similarly, the plate and modular hooks may be secured to the scapular spine either above the scapular spine, below the scapular spine, or along the side of the scapular spine (see, e.g., Figures 7A-7F). In some embodiments, for even more compound morphological variability or to better withstand comminution of complex fractures, the plate itself is also modular (see, e.g., Figures 8A-8E) and may also be used in connection with modular hooks. In some embodiments, such a modular connection may have angular/tilt variability and also variability in rotation and position.

In some embodiments, the screw fixation holes can be placed in different locations and orientations on the plate to facilitate reconstruction and compression across the fracture lines and to impart additional stability for each of the different fracture types. In some embodiments, these modular hooks can also accept screws for additional fixation (see, e.g., Figures 4C and 4D ). Furthermore, in some embodiments, numerous holes of various sizes for sutures and wires can be designed to facilitate reconstruction. In some embodiments, the sizes of such holes are selected to allow needles of various sizes to easily pass through them with the plate compressed against the bone. In some embodiments, the edges of the suture holes are configured so as not to abrade a suture when the suture is secured against the plate.

In some embodiments, the plates and modular hooks are provided in multiple different sizes and shapes to account for the various types of acromion and scapula fractures that an orthopedic surgeon may present with following rTSA, namely: Type 1, Type 2, and Type 3 scapular fractures as discussed above. The accompanying figures for the exemplary embodiments depict multiple views of different design variations of the proposed device to account for different possible fracture locations. For example, as depicted in Figures 5E, 5F, 6E, 6F, 7E, and 7F, for a Type 1 or Type 2 fracture, a modular hook may be placed laterally on the acromion, along or around different regions of the acromion, and/or in a different location (e.g., posteriorly, anteriorly, or medially on the scapula, etc.). In contrast, for a type 2 or type 3 fracture as depicted in Figures 5E, 5F, 7E, and 7F, a modular hook may be placed over or under the scapular spine, medially on the scapula at or around the scapular trigone, and/or in a different location (e.g., posterior, anterior, or medially on the scapula, etc.).

In some embodiments, the plates and modular hooks are provided in multiple different shapes and sizes for each fracture type and are provided in a range of sizes and shapes to account for the normal anatomical variation of the different anatomical morphology of the acromion and scapular spine. For example, as depicted in Figures 5B-5D and 6C-6F, an exemplary plate and modular hook may be configured to be secured to the top of the scapular spine and acromion and then rotated to the side or bottom surface of the scapular spine for further multi-planar mounting. Conversely, as depicted in Figures 7C-7F, an exemplary plate may be positioned on top of the scapular spine and may be rotated to the bottom surface of the acromion. In some embodiments, different extensions and shapes are configured or modularly joined to provide multiple options and diverse positions for screw/suture/wire fixation to the scapula and to obtain greater fixation between the bone fragments.

Figure 4A shows a perspective view of a first hook 400 that may be part of an acromion/scapula fracture repair system. In some embodiments, the hook 400 is sized and shaped for fixation adjacent to the lateral acromion. In some embodiments, the hook 400 includes a mount 402 that is configured to mount the hook 400 to a plate, a first hook portion 404 proximate the mount 402, a spacer portion 406 extending away from the first hook portion 404, and a second hook portion 408 at the end of the spacer portion 406 opposite the first hook portion 404.

Figure 4B shows a perspective view of a second hook 410 that may be part of an acromion/scapula fracture repair system. In some embodiments, the hook 410 is sized and shaped for fixation adjacent to the medial scapular blade near the trigone. In some embodiments, the hook 410 is sized and shaped for fixation on the top of the acromion. In some embodiments, the hook 410 includes a mount 412 that is configured to mount the hook 410 to a plate, a curved portion 414 that extends away from and curves rearwardly toward the mount 412, and a Y-shaped hook portion 416 at the end of the curved portion 414 opposite the mount 412.

Figure 4C shows a perspective view of a third hook 420 that may be part of an acromion/scapula fracture repair system. In some embodiments, the hook 420 is sized and shaped for fixation along the scapular spine. In some embodiments, the hook 420 includes a mount 422 that is configured to mount the hook 420 to a plate, a curved portion 424 that extends away from and curves rearwardly toward the mount 422, a hook portion 426 at the end of the curved portion 424 opposite the mount 422, and a fixation hole 428 that extends through the hook portion 426 and configured to receive an attachment element (e.g., a screw) extending therethrough to provide enhanced fixation. Figure 4D shows a perspective view of a portion of a plate 430 and two of the third exemplary hook 420. As shown in Figure 4D, in some embodiments, for each of the hooks 420, a screw 440 secures the hook 420 to the plate 430 by installing through a hole 432 of the plate 430, the mount 422 of the hook 420, and the fixing hole 428 of the hook 420.

Figures 5A and 5B show perspective views of a first plate 500. In some embodiments, plate 500 is sized and shaped to be positioned along the scapular spine of a patient. In some embodiments, plate 500 includes a first end 502 (e.g., a medial end) and a second end 504 (e.g., a lateral end). In some embodiments, plate 500 includes a plurality of fixation points 506 (e.g., holes) extending therethrough and configured to facilitate fixation of plate 500 to a bone by mechanical fixation devices such as screws, sutures, wires, pins, etc. In the embodiment of plate 500 shown in Figures 5A and 5B, plate 500 includes ten (10) of the attachment points 506, but it will be apparent to those skilled in the art that this number is exemplary only and that plate 500 may include any number of the attachment points 506.

Figures 5C and 5D show a perspective view of the plate 500 prepared to be secured to a scapula of a patient. As shown in Figures 5C and 5D, the plate 500 has been prepared by securing one of the second hook 410 to the first end 502 and securing one of the first hook 400 to the second end 504. In some embodiments, as shown in Figures 5C and 5D, the first hook 400 and the second hook 410 are secured to the plate 500 by screws 510. The combination of the plate 500, the first hook 400, the second hook 410, and the screws 510 is referred to herein as construction 520.

Figures 5E and 5F show perspective views of a representative scapula S, with construct 520 secured thereto. Figure 5E shows a posterior view, and Figure 5F shows an anterior view. As shown in Figures 5E and 5F, second hook 410 extends around the medial scapular blade near the trigone, plate 500 extends along the scapular spine, and first hook 400 extends around the lateral acromion. In some embodiments, screws 510 extend into the scapula to secure construct 520 thereto. In some embodiments, first hook 400, plate 500, second hook 410, and screws 510 cooperate to retain the acromion in a desired (e.g., anatomically correct) position.

Figures 6A and 6B show perspective views of a second plate 600. In some embodiments, plate 600 is sized, shaped, and curved to extend along a scapular spine and acromion of a patient. In some embodiments, plate 600 includes a first end 602 (e.g., a medial end) and a second end 604 (e.g., a lateral end). In some embodiments, plate 600 includes a plurality of fixation points 606 (e.g., holes) extending therethrough and configured to facilitate fixation of plate 600 to a bone by mechanical fixation devices such as screws, sutures, wires, pins, etc. In the embodiment of plate 600 shown in Figures 6A and 6B, plate 600 includes thirteen (13) of the attachment points 606, but it will be apparent to those skilled in the art that this number is exemplary only and that plate 600 may include any number of the attachment points 606.

Figures 6C and 6D show perspective views of plate 600 prepared for attachment to a patient's scapula. Figure 6C shows a posterior perspective view, and Figure 6D shows an anterior perspective view. As shown in Figures 6C and 6D, plate 600 is prepared by securing one of third hook 420 to second end 604. In some embodiments, as shown in Figures 6C and 6D, third hook 420 is secured to plate 600 by screw 610. The combination of plate 600, third hook 420, and screw 610 is referred to herein as construction 620.

Figures 6E and 6F show perspective views of a representative scapula S, with construct 620 secured thereto. Figure 6E shows a posterior view, and Figure 6F shows a side view. As shown in Figures 6E and 6F, plate 600 extends along the scapular spine and curves to extend along the acromion, and third hook 420 extends around the top of the acromion. In some embodiments, screw 610 extends through the acromion to secure construct 620 thereto. In some embodiments, plate 600, third hook 420, and screw 610 cooperate to retain the acromion in a desired (e.g., anatomically correct) position.

Figures 7A and 7B show perspective views of a third plate 700. In some embodiments, plate 700 is curved such that, when plate 700 is positioned adjacent to a patient's scapula, first end 702 is positioned along the underside of the scapular spine and second end 704 is positioned along the posterior side of the acromion. In some embodiments, plate 700 includes a plurality of fixation points 706 (e.g., holes) extending therethrough and configured to facilitate fixation of plate 700 to a bone by mechanical fixation devices such as screws, sutures, wires, pins, etc. In the embodiment of plate 700 shown in Figures 7A and 7B, plate 700 includes eight (8) of the attachment points 706, but it will be apparent to those skilled in the art that this number is exemplary only and that plate 700 may include any number of the attachment points 706.

Figures 7C and 7D show perspective views of plate 700 prepared for attachment to a patient's scapula. Figure 7C shows a posterior perspective view, and Figure 7D shows an anterior perspective view. As shown in Figures 7C and 7D, plate 700 is prepared by securing a first hook of third hook 420 to the first end 702, a second hook of third hook 420 between the first and second ends 702, 704, and a third hook of hooks 420 to the second end 704. In some embodiments, as shown in Figures 7C and 7D, third hooks 420 are secured to plate 700 by a screw 710. The combination of plate 700, third hooks 420, and screws 710 is referred to herein as construction 720.

Figures 7E and 7F show perspective views of a representative scapula S, with construct 620 secured thereto. As shown in Figures 7E (posterior view) and 7F (posterior oblique view), plate 700 extends along the underside of the scapular spine from first end 702 of plate 700 and curves to extend along the back of the scapular spine and the back of the acromion as it extends toward second end 704 of plate 400. First and second of third hooks 420 secure plate 700 to the scapular spine, and third of hooks 420 secures the plate to the acromion. In some embodiments, screws 710 extend through the scapular spine and acromion to secure construct 710 thereto. In some embodiments, plate 700, hooks 420, and screws 710 cooperate to retain the acromion in a desired (e.g., anatomically correct) position. In some embodiments, plate 700, hooks 420, and screws 710 cooperate to retain the acromion in a desired (e.g., anatomically correct) position.

Figures 8A and 8B show perspective views of a fourth plate 800. The fourth plate 800 is an adjustable plate. Figures 8A and 8B show the fourth plate 800 from substantially the same perspective as each other, with the plate 800 shown adjusted in a first position in Figure 8A and in a second position in Figure 8B. The plate 800 includes a scapular plate 810, an acromial plate 820, and a modular joint 830 connecting the acromial plate and the scapular plate. In some embodiments, the modular joint is a ball-and-socket connection that allows for adjustment of the angle of the joint between the scapular plate 810 and the acromial plate 820, thereby allowing the position of the acromial plate 820 to be adjusted to account for individual patient acromial morphology and bone shape (e.g., acromial tilt). In some embodiments, the modular joint 830 may be secured/fastened, such as with a screw, to thereby fix the position of the scapular plate 810 and the acromial plate 820 relative to each other. In some embodiments, the scapular plate 810 is sized and shaped to extend along a patient's scapular spine. In some embodiments, the acromial plate 820 is sized and shaped to extend along a patient's acromion spine. In some embodiments, the plate 800 includes a plurality of fixation points 840 (e.g., holes) extending therethrough and configured to facilitate fixation of the plate 800 to a bone by mechanical fixation devices such as screws, sutures, wires, pins, etc. In the embodiment of plate 800 shown in Figures 8A and 8B, plate 800 includes twelve (12) of the attachment points 840, of which nine (9) of the attachment points 840 are located along scapular plate 810 and three (3) of the attachment points 840 are located along acromial plate 820, but it will be apparent to those skilled in the art that this number is exemplary only and that plate 800 may include any number of the attachment points 840. In some embodiments, plate 800 is configured to allow any of the hooks described herein (e.g., first hook 400, second hook 410, and/or third hook 420) to be secured thereto to facilitate fixation to the scapula.

Figure 8C shows a side view of the plate 800 of Figures 8A and 8B. In the view of Figure 8C, the acromial plate 820 is shown positioned in two alternative positions 820A and 820B relative to the scapular plate 810. It can be seen in Figure 8C that the adjustable positioning of the acromial plate 820 allows the plate 800 to be adjusted to properly fit patients having varying anatomy, for example, acromions with different angles.

Figures 8D and 8E show perspective views of a representative scapula S, with plate 800 positioned adjacent thereto. Figures 8D (posterior view) and 8E (posterior oblique view) show plate 800 in the absence of hooks (e.g., first hook 400, second hook 410, and/or third hook 420) and screws (or other similar fastening mechanisms), but it will be apparent to those skilled in the art that these figures are illustrative only and that practical applications of plate 800 may include such additional elements. As shown in Figures 8D and 8E, scapular plate 810 extends along the superior side of the scapular spine, modular attachment 830 is positioned near the base of the acromion, and acromial plate 820 extends along the acromion. In some embodiments, plate 800, used in conjunction with one or more hooks (e.g., first hook 400, second hook 410, and/or third hook 420) and screws, is configured to retain the acromion in a desired (e.g., anatomically correct) position.

In some examples, the devices are provided in multiple different sizes and shapes to account for the various types of fracture that may be presented to the orthopedic surgeon. In some examples, exemplary devices are provided in different shapes for the different types of scapular fractures (i.e., type 1 fractures as shown in Figures 3C and 3D, type 2 fractures as shown in Figures 3E and 3F, and type 3 fractures as shown in Figures 3G and 3H) described above, each of which corresponds to a fracture at a different location within the scapula.

In some examples, a device includes one or more extensions or shapes to provide multiple options for screw fixation in the scapula to obtain greater fixation to the native bone. In some examples, such extensions are integrally formed with an exemplary scapular fixation device. In some examples, such extensions can be modularly attached to and removed from a scapular fixation device. In some examples, at least one of said extensions is configured to provide an option for screw fixation oriented towards the superior part of the scapular spine. In some examples, at least one of said extensions is configured to provide an option for screw fixation oriented towards the inferior part of the scapular spine. In some examples, at least one of said extensions is configured to provide an option for screw fixation adjacent to the medial border to the superior part of the scapular spine. In some examples, at least one of said extensions is configured to provide an option for screw fixation adjacent to the medial border to the inferior part of the scapular spine.

It should be noted that each of the embodiments described herein may be secured to one or more regions of the acromion or scapular spine to provide additional strength and rigidity at the time of the initial reverse shoulder arthroplasty procedure (i.e., before a fracture occurs). By prophylactically securing such a plate to regions of the scapula that are subjected to high stress following rTSA, the incidence of acromial and/or scapular fractures following rTSA may be reduced as either device may offload the bone and better distribute the load. In some embodiments, a strut is secured between the coracoid and/or clavicle to better offload and distribute the load (e.g., stress transmission) to other portions of the scapula. In practice, any of the examples described herein may be used individually or in combination with each other at the discretion of the orthopedic surgeon to better anatomically reconstruct the fractured bones and achieve compression of the fragment, either after the fracture occurs or prophylactically.

In some embodiments, any of the embodiments described above may be manufactured to be flexible or otherwise adaptable to facilitate additional patient-specific shaping to improve initial fixation when repairing the patient's acromion and scapula. In some embodiments, the shape and contour of each of the modular hooks (e.g., first hook 400, second hook 410, and/or third hook 420) may be bent to better conform to the morphology of the patient's scapula along any of the medial, lateral, anterior, or posterior regions of the scapula. In some embodiments, sutures, tapes, anchors, or screws may be used to secure soft tissue to any of the embodiments described herein. Any of the examples described herein can be fabricated from various biocompatible materials, including Co-Cr, stainless steel, titanium, titanium alloys, carbon fiber reinforced polymers, ceramics, PMMA bone cement, pyrocarbon, and/or bone graft. Any of the examples described herein can include textures and/or surface coatings to provide additional mechanical fixation and to promote osseointegration. Any of the examples described herein can be fabricated by traditional computer-aided manufacturing processes, forged, cast, injection molded, or by using additive manufacturing or similar processes. Any of the examples described herein can be designed based on the patient's actual anatomy (or contralateral anatomy) by using CT reconstruction and computer modeling. Any of the examples described herein can be surface coated or treated with various processes to promote fixation to soft tissue, muscle, and/or bone.

In some examples, a device is formed from a metal plate that is cut and shaped to a desired size and shape. In some examples, the plate has a thickness in a range of between 3 mm and 10 mm. In some embodiments, the thickness is in a range of between 3 mm and 9 mm. In some examples, the thickness is in a range of between 3 mm and 8 mm. In some examples, the thickness is in a range of between 3 mm and 7 mm. In some examples, the thickness is in a range of between 3 mm and 6 mm. In some examples, the thickness is in a range of between 3 mm and 5 mm. In some examples, the thickness is in a range of between 3.5 mm and 4.5 mm. In some examples, the thickness is about 4 mm. In some examples, the thickness is 4 mm.

In some examples, the screw holes of a device have a diameter in the range of 1.0 mm to 4.5 mm. In some examples, the screw holes have a diameter in the range of 1.5 mm to 4.0 mm. In some examples, the screw holes have a diameter in the range of 2.0 mm to 3.5 mm. In some examples, the screw holes have a diameter in the range of 2.5 mm to 3.0 mm. In some examples, the screw holes have a diameter in the range of 1.0 mm to 4.0 mm. In some examples, the screw holes have a diameter in the range of 1.0 mm to 3.5 mm. In some examples, the screw holes have a diameter in the range of 1.0 mm to 3.0 mm. In some examples, the screw holes have a diameter in the range of 1.0 mm to 2.5 mm. In some examples, the screw holes have a diameter in the range of 1.0 mm to 2.0 mm. In some examples, the screw holes have a diameter in the range of 1.0 mm to 1.5 mm. In some examples, the screw holes have a diameter in the range of 1.5 mm to 4.5 mm. In some examples, the screw holes have a diameter in the range of 2.0 mm to 4.5 mm. In some examples, the screw holes have a diameter in the range of 2.5 mm to 4.5 mm. In some examples, the screw holes have a diameter in the range of 3.0 mm to 4.5 mm. In some examples, the screw holes have a diameter in the range of 3.5 mm to 4.5 mm. In some examples, the screw holes have a diameter in the range of 4.0 mm to 4.5 mm.

In some examples, in areas of the device where screw holes are present, the screw holes may be separated from each other by a separation distance (i.e., measured center-to-center or edge-to-edge). In some examples, the separation distance is between 1.0 cm and 4.0 cm. In some examples, the separation distance is between 1.5 cm and 3.5 cm. In some examples, the separation distance is between 2.0 cm and 3.0 cm. In some examples, the separation distance is between 2.5 cm and 3.5 cm. In some examples, the separation distance is between 1.0 cm and 3.5 cm. In some examples, the separation distance is between 1.0 cm and 3.0 cm. In some examples, the separation distance is between 1.0 cm and 2.5 cm. In some examples, the separation distance is between 1.0 cm and 2.0 cm. In some examples, the separation distance is between 1.0 cm and 1.5 cm. In some examples, the separation distance is between 1.5 cm and 4.0 cm. In some examples, the separation distance is between 2.0 cm and 4.0 cm. In some examples, the separation distance is between 2.5 cm and 4.0 cm. In some examples, the separation distance is between 3.0 cm and 4.0 cm. In some examples, the separation distance is between 3.5 cm and 4.0 cm.

Throughout the specification and claims, the following terms take on the meanings explicitly assigned herein, unless the context clearly indicates otherwise. The phrases "in one embodiment," "in one embodiment," and "in some embodiments" as used herein do not necessarily refer to the same embodiment(s), although they may. Furthermore, the phrases "in another embodiment" and "in some other embodiments" as used herein do not necessarily refer to a different embodiment, although they may.

As used herein, the term "based on" is non-exclusive and permits reliance on additional factors not described, unless the context clearly indicates otherwise. Furthermore, throughout the specification, the meanings of "a," "an," and "the" include plural references. The meaning of "in" includes "in" and "upon."

Claims (14)

1. A kit, comprising: - at least one plate (430, 500, 600, 700, 800), wherein each of the at least one plate (430, 500, 600, 700, 800) includes a plurality of fixing points (506, 606, 706, 840) that are spaced apart along each of the at least one plate (430, 500, 600, 700, 800), wherein the at least one plate (430, 500, 600, 700, 800) includes at least a first plate (430, 500, 600, 700, 800) which is an elongated plate (430, 500, 600, 700, 800) having a first end (502, 602, 702) and a second end (504, 604, 704) opposite the first end (502, 602, 702), and - a plurality of hooks (400, 410, 420), wherein each of the hooks (400, 410, 420) is configured to be fixed to a selected one of the fixing points (506, 606, 706, 840) of a selected one of the at least one plate (430, 500, 600, 700, 800), wherein the plurality of hooks (400, 410, 420) includes at least: - a first hook including (a) a mount (402, 412, 420) that is configured to be fixed to a selected one of the fixing points (506, 606, 706, 840) of a selected one of the at least one plate (430, 500, 600, 700, 800), (b) a first hook portion (404) positioned proximate the mount (402, 412, 420) and extending away from the mount (402, 412, 420) in a first direction, (c) a spacer portion (406) extending away from the first hook portion (404) in a transverse direction that is perpendicular to the first direction, and (d) a second hook portion (408) extending from an end of the spacer portion (406) that is opposite the first hook portion (404) and extends in the first direction, wherein the first hook (400, 410, 420) is sized and shaped to be configured such that the first and second hook portions (408) extend around a lateral end of the acromion when the first hook (400, 410, 420) is attached to a first of the attachment points (506, 606, 706, 840) of the first plate (430, 500, 600, 700, 800) that is proximate the second end (504, 604, 704) of the plate (430, 500, 600, 700, 800), and - a second hook (400, 410, 420) including (a) a mount (402, 412, 420) that is configured to be fixed to a selected one of the fixing points (506, 606, 706, 840) of a selected one of the at least one plate (430, 500, 600, 700, 800), (b) a curved portion that extends away from and curves back toward the mount (402, 412, 420), and (c) a hook portion (400, 410, 420) at an end of the curved portion that is opposite the mount (402, 412, 420) of the second hook (400, 410, 420), wherein the second hook (400, 410, 420) is sized and shaped to be configured so that that the hook portion (400, 410, 420) of the second hook (400, 410, 420) extends around the trigone of the scapula when the second hook (400, 410, 420) is fixed to a second of the fixation points (506, 606, 706, 840) of the first plate (430, 500, 600, 700, 800) that is proximate the first end (502, 602, 702) of the first plate (430, 500, 600, 700, 800). The first plate (430, 500, 600, 700, 800). 2. The kit of claim 1, wherein the first plate (430, 500, 600, 700, 800) is contoured to fit the scapular spine. 3. The kit of claim 1 or 2, wherein at least one of the at least one plate (430, 500, 600, 700, 800) is adaptable to allow a user to adapt the plate (430, 500, 600, 700, 800) to a portion of the scapula. 4. The kit of one of claims 1 to 3, wherein the hook portion (400, 410, 420) of the second hook (400, 410, 420) is Y-shaped. 5. The kit of one of claims 1 to 4, wherein the first plate (430, 500, 600, 700, 800), the first hook (400, 410, 420), and the second hook (400, 410, 420) are configured to cooperate to apply a compressive force to a fracture along the scapular spine when (a) the first plate (430, 500, 600, 700, 800) is secured to the scapular spine, (b) the first hook (400, 410, 420) is fixed to the first of the fixation points (506, 606, 706, 840) of the first plate (430, 500, 600, 700, 800) and positioned such that the first and second portions of (c) the second hook (400, 410, 420) is fixed to the second of the attachment points (506, 606, 706, 840) of the first plate (430, 500, 600, 700, 800) and positioned such that the hook portion (400, 410, 420) of the second hook (400, 410, 420) extends around the lateral end of the acromion, and 6. The kit of one of claims 1 to 5, further comprising at least one fastener configured to be attached to one of the attachment points (506, 606, 706, 840) of one of the at least one plate (430, 500, 600, 700, 800), the plate (430, 500, 600, 700, 800), and the scapula for attaching the at least one plate (430, 500, 600, 700, 800) to the scapula. 7. The kit of one of claims 1 to 6, further comprising at least one fastener configured to be attached to one of the attachment points (506, 606, 706, 840) of one of the at least one plate (430, 500, 600, 700, 800) and to a selected one of the plurality of hooks (400, 410, 420) for attaching the selected one of the plurality of hooks (400, 410, 420) to the one of the at least one plate (430, 500, 600, 700, 800). 8. The kit of one of claims 1 to 7, wherein the at least one plate (430, 500, 600, 700, 800) also includes a second plate (430, 500, 600, 700, 800), wherein the second plate (430, 500, 600, 700, 800) has a first end (502, 602, 702) and a second end (504, 604, 704) opposite the first end (502, 602, 702) of the second plate (430, 500, 600, 700, 800), wherein the second plate (430, 500, 600, 700, 800) is a curved plate (430, 500, 600, 700, 800) which is sized and shaped to be configured to be positioned adjacent the patient's scapular spine and the patient's acromion such that the first end (502, 602, 702) of the second plate (430, 500, 600, 700, 800) is positioned proximate the patient's spine and the plate (430, 500, 600, 700, 800) extends along the patient's scapular spine and the patient's acromion to the second end (504, 604, 704) which is positioned proximate the top of the patient's acromion. 9. The kit of one of claims 1 to 8, wherein the second hook (400, 410, 420) is sized and shaped to be configured such that the hook portion (400, 410, 420) of the second hook (400, 410, 420) extends around the top of the patient's acromion when the second hook (400, 410, 420) is attached to one of the attachment points (506, 606, 706, 840) of the second plate (430, 500, 600, 700, 800) that is located near the second end (504, 604, 704) of the second plate (430, 500, 600, 700, 800). 10. The kit of one of claims 1 to 9, wherein the at least one plate (430, 500, 600, 700, 800) includes a second plate (430, 500, 600, 700, 800) which is an elongated plate (430, 500, 600, 700, 800) having a first end (502, 602, 702) and a second end (504, 604, 704) opposite the first end (502, 602, 702) of the second plate (430, 500, 600, 700, 800), wherein the second plate (430, 500, 600, 700, 800) has a size and shape to be configured to be positioned along the scapular spine and extend along the scapular spine from the first end (502, 602, 702) which is positioned along an inferior surface of the scapular spine to the second end (504, 604, 704) which is positioned on a posterior surface of the acromion. 11. The kit of claim 10, wherein the plurality of hooks (400, 410, 420) includes a third hook (400, 410, 420) that includes (1) a mount (402, 412, 420) that is configured to attach to a selected one of the attachment points (506, 606, 706, 840) of a selected one of the at least one plate (430, 500, 600, 700, 800), (2) a curved portion extending away from and curving back toward the mount (402, 412, 420), and (3) a hook portion (400, 410, 420) at an end of the curved portion that is opposite the mount (402, 412, 420) of the second hook (400, 410, 420). 410, 420), and (4) a fixing hole extending through the hook portion (400, 410, 420), wherein the fixing hole is configured to receive a fastener for fixing the hook portion (400, 410, 420) to the scapula. 12. The kit of claim 11, wherein the third hook (400, 410, 420) is sized and shaped to be configured such that the hook portion (400, 410, 420) extends over an upper surface of the scapular spine when the second plate (430, 500, 600, 700, 800) is positioned along the scapular spine and the second hook (400, 410, 420) is attached to one of the attachment points (506, 606, 706, 840) of the second plate (430, 500, 600, 700, 800) that is positioned along the lower surface of the scapular spine. 13. The kit of claim 11 or 12, further comprising a fastener that is configured to attach to both the mount (402, 412, 420) and the third hook attachment hole (400, 410, 420). 14. The kit of claim 13, wherein the fastener is configured to extend through the frame (402, 412, 420), the scapular spine, and the attachment hole of the third hook (400, 410, 420) when (a) the second plate (430, 500, 600, 700, 800) is positioned along the scapular spine and (b) the third hook (400, 410, 420) is attached to one of the attachment points (506, 606, 706, 840) of the second plate (430, 500, 600, 700, 800) that is positioned along the lower surface of the scapular spine such that the rotation of the hook (400, 410, 420) of the third hook (400, 410, 420) extends over the upper surface of the scapular spine.